Provider Demographics
NPI:1114718491
Name:KISS, REBECCA ANNE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANNE
Last Name:KISS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 DEBORAH DR
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:CT
Mailing Address - Zip Code:06238-1323
Mailing Address - Country:US
Mailing Address - Phone:860-539-5154
Mailing Address - Fax:
Practice Address - Street 1:2 CORPORATE DR STE 9559TH
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6238
Practice Address - Country:US
Practice Address - Phone:860-929-7353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT149105367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered